Posts or Comments 20 July 2024

Monthly Archive for "June 2011"

Corruption &Funding Bill Brieger | 28 Jun 2011

Global Fund’s OIC Grabs Nigeria

The Daily Trust Newspaper today has a shocking front page headline: ‘N7bn malaria, HIV funds frittered’ (that’s Naira). This is equivalent to US $475 million. No principal recipient (PR) appears to be left unscathed. Specifically the article leads with the assertion that …

About N7 billion donor funds sent to Nigeria for the fight against malaria, HIV and tuberculosis were frittered away, according to an audit report by the international agency that provided the funds. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) said in a report filed with the Independent Corrupt Practices Commission that beneficiary agencies failed to account for up to $475 million meant to “save lives”.

The story is based on a report from the Global Fund’s Office of the Inspector General (OIG) who discovered “the fraud in a recent audit of 15 grants amounting to $474,519,260 disbursed between 2003 and 2009 for the purpose of saving lives in the country.” Nigeria has had three GFATM malaria grants over this period.

As is usual though the OIG paints both ‘minor’ accounting problems as well as gross misconduct with the same brush. The most egregious offender appears to be the Yakubu Gowon Centre (YGC). YGC has been a malaria PR since Nigeria received its first GFATM grant and almost lost that grant due to poor performance about five years ago.

Currently YGC is one of three GFATM Round 8 malaria grant PRs.  In terms of the most current performance ratings, The Society for Family Health was rated B1, The National Malaria Control Program was rated B2, while the YGC received a ‘C’ – the lowest or a failing grade by Global Fund accounting.

The Daily Trust quotes the OIG report The report thus: “The value for money audit report indicates that the Yakubu Gowon Centre for International Cooperation illegally transferred funds outside the country amounting to $15.5million, incurred extra budgetary expenditures of $5.2m, and had undocumented expenditures amounting to $3m. The unretired expenditures of the centre for the period under review amounted to $1.2m, while the management fee not accounted for was $659,000.”

ygc-performance-report-sm.jpgThe GFATM progress report says of the YGC performance on the Round 8 malaria grant that the average programmatic performance is 34.7% among all the program targets.  In fact some states served by the YGC are reporting stock out of malaria drugs much needed for saving lives.

It is certainly good that the IOG identified major misconduct that threatens progress to control malaria. The question is who will pick up the slack in malaria commodity supplies while all this is being sorted out?

Civil Society Bill Brieger | 27 Jun 2011

Community Transportation System to Save Maternal Lives

dscn2401sm.jpgGuest contribution from: Ahmed Mohammed Ahmed, Community Mobilization Specialist, Targeted States High Impact Project (TSHIP), Bauchi State, Nigeria

TSHIP aims to improve maternal and child health in Nigeria by strengthening health services and enhancing community participation. An example of the latter follows:

Five Ward Development Committees [WDCs] in Pali and Kungibar Districts of Alkaleri Local Government Area in  Bauchi State have initiated a community approach to emergency transportation for pregnant women and children.  This is at the background to recent 2OO8 NDHS survey which showed high rates of maternal and child mortalities in the North-East part of Nigeria.

dscn2450sm.jpgThe initiative which saw a strong commitment on the parts of different community and ward structures like the National Union of Road Transport Workers [NURTW], Okada Riders Association (motorcycle taxi drivers), Health Providers, Traditional and Religious leaders, was witnessed by other stakeholders such as Alkaleri LGA whose Chairman was represented at the occasion by the Director PHC.

The event was marked with a short drama presentation (see at right) highlighting the objective of the Emergency Transport Team [ETT], which is to provide free transport service to pregnant women and children under 5 from all the communities within the five wards.  Mobile phone numbers of the executive committee members and that of other drivers and motorcycle drivers in the scheme were provided at the inauguration for ease of contact. (see transportation committee members at left)

dscn2443sm.jpgIn his brief speech at the occasion, the visiting Chairman of Bara WDC in Kirfi, Malam Haruna Katukan Bara, says ‘I am here to learn about this unique experience and also help my ward in replicating it.’ He also urge community members to support the good works of the WDCs towards the development of humanity.

Finally, one of the community’s traditional birth attendants (right) thanked the committee for taking action to save the lives of pregnant women in the wards.

IPTp &Malaria in Pregnancy &Surveillance Bill Brieger | 18 Jun 2011

The changing face of malaria in maternal health

Jhpiego organized a panel attended by over 80 people at the just concluded Global Health Council annual conference entitled, “The changing face of malaria in maternal health,” moderated by Bill Brieger and coordinated by Aimee Dickerson. The overlap between high malaria prevalence and high maternal mortality in Africa was stressed. Although both are generally decreasing, the pace of change is quite slow for meeting Millennium Development Goals and malaria elimination targets. The time of neglecting malaria in pregnancy (MIP) should be over.

malaria-risk-maternal-mortality-sm.jpgAs efforts increase toward malaria elimination and the epidemiology of malaria changes, we need to be prepared at the country and global levels. This was illustrated through four presentations that focused on …

  1. Nigeria, a high burden country, needs to consider ways to scale up
  2. Rwanda, a country closing in on elimination, needs to more carefully define and target MIP transmission
  3. New interventions developed through research and
  4. Rolling out these new interventions through donor support

Enobong Ndekhedehe of Community Partners for Development based in Akwa Ibom State Nigeria spoke on community involvement to increase IPTp & ITN coverage in a highly endemic area. This joint project with Jhpiego, sponsored by the ExxonMobil Foundation, showed successfully that community volunteers supported by front-line antenatal clinic staff could greatly increase uptake of intermittent preventive treatment and thus provided a model for scale up in a high burden country.

Corine Karema who heads the National Malaria Control Program in the Rwanda Ministry of Health, addressed the feasibility of determining the prevalence of MIP during ANC in an era of declining incidence. Intense distribution of long lasting insecticide treated nets and wide availability of artemisinin-based combination therapy for malaria treatment at the community level have resulted in a 70% decline in malaria incidence between 2005 & 2010. Good ANC coverage and availability of staff to test pregnant women on their first ANC visit were found to bode well for providing not only an opportunity for pregnancy-specific prevalence determination, but also an opportunity for future interventions based on routing screening and treatment.

dscn2285sm.jpgTheonest Mutabingwa from the Hubert Kairuki Memorial University, Tanzania talked on “The future MIP research agenda in the context of malaria elimination,” based on the plans and experiences of the Malaria in Pregnancy Consortium (MIPc), of which he is a member. MIPc teams from African and northern research institutes are looking into such issues as the changing role of prevention (e.g. IPTp vs screening and treatment), When is it optimal to change interventions (use of modelling), what are the changing patterns of disease epidemiology and immunity in pregnant women, what are the criteria or thresholds upon which to switch control strategies, what should constitute guidelines to define high/moderate, low and very low transmission settings, among others.

Finally Jon Eric Tongren of the US President’s Malaria Initiative (PMI) provided a donor’s  perspective on MIP programming in countries with changing malaria epidemiology. This presentation showed that even with input from multiple donors, MIP intervention targets for IPT and LLIN use are well below the RBM 2010 goal of 80% and the PMI goal of 85% despite demonstrated increases in coverage of both services. Even though effective MIP interventions exist, they need to be strengthened through well-executed assessments, collaborative implementation, and careful follow-up, monitoring, and evaluation. Echoing the research agenda expressed before, the presenter stressed the need for continued surveillance to map progress and change in prevalence and adaptation of MIP strategies as prevalence changes.

MIP control faces a double challenge. Since this component of national malaria control programs has often been neglected, there is a need to catch up and achieve 2010 coverage targets. Then moving forward, strengthened monitoring and surveillance is needed to fine tune, revise and better target MIP interventions to make a bigger impact on reducing maternal mortality in endemic countries.

Civil Society &Funding Bill Brieger | 05 Jun 2011

China – an odd position with the Global Fund

China has recently made the news because grants from the Global Fund have been frozen over non-adherence to GFATM procedures. As reported on Yahoo Health News a spokesperson for the Global Fund said, “We believe that the main recipient, the CDC (China Centers for Disease Control), had violated an accord of the Global Fund which said that a part of the financing accorded, at least 35 percent, must go through community organisations.” As Yanzhong Huang explained, “The (Chinese) government may like the Global Fund money, but it obviously does not like the Global Fund’s ideas as far as civil society is concerned.”

To date, China has been awarded 14 GFATM grants covering all three diseases. Generally the grants have performed well. These grants have a lifetime budget of nearly $2 billion of which nearly $1 billion has been approved.

Let us compare this scenario against the world economic picture. Last August the New York Times reported that, “After three decades of spectacular growth, China passed Japan in the second quarter to become the world’s second-largest economy behind the United States, according to government figures released early Monday.”

To date China has pledged $30 million to the GFATM, and paid $20 million. China is not the only recipient country to contribute. Even Nigeria, whose economy is nowhere near as large as China’s has pledged $29 million and paid $19 million. Other recipients who have provided some support range from Malaysia to Rwanda.

In the end when one looks at a $30 million pledge compared to $2 billion worth of gain by the second largest economy in the world, one wonders why China does not or can not shift over to the donor side of the equation completely.

The thoughts of Yanzhong Huang on how to deal with this situation might be construed as appeasement. “In order to encourage the participation of China’s civil society groups in global health, it is important to allay the fears of Chinese leaders.” A harsher approach might be to say that if China no longer received GFATM money, there may be no need to allay fears. As the world economy slows, more of the G20 countries need to think seriously about how they can step up to the donor table and behave as if it were better to give than receive.

Peace/Conflict Bill Brieger | 04 Jun 2011

Refugees may escape conflict, but not malaria

We have looked at the exacerbation of malaria in conflict situations before, and unfortunately will probably need to look at the issue again.  A new article in Malaria Journal shows that even when refugees escape from the conflict zone, they may still be confronted by malaria in their camps.

Bayoh and colleagues looked at Kakuma refugee situated in Turkana District in the semi-arid north-west region of Kenya, an area that is normally not too hospitable to malaria. The researchers found that human activity was responsible for mosdquitoe breeding. “All of the habitats encountered in the dry season were associated directly with tap-stands, and were either cemented pits, soil-lined pits, drainage channels, or run-off puddles whose water source was from the tap-stands.”

Even in the short rainy season, “The habitats encountered … were primarily maintained by water from tap-stands.” These included cemented pits, soil-lined pits, drainage channels, and run-off puddles (90% of all habitats). Transportation lent a hand through wet tire tracks and roadside puddles.

jhu-public-health-guide-in-emergencies.jpgThe researchers in Kakuma were aided by rapid diagnostic tests and microscopy in diagnosing and subsequently treating those suffering from malaria.  This is not always the case. Akello-Ayebara and co-workers documented inappropriate treatment of refugee children in northern Uganda. Obviously self-diagnosis presented problems, but misdiagnosis by local health care providers was common.

They concluded that, “The local diagnostic system needs to be improved, not only so that malaria can be reliably diagnosed but also so that alternative diagnoses can be confirmed or rejected, otherwise the current over-consumption of antimalarial drugs may simply be replaced with an over-consumption of antibiotics.”

Malaria problems for refugees are not confined to Africa. Basseri and colleagues document that in Asia refugees coming into a malaria endemic area are less likely to have protective measures like nets than the indigenous population.

The last two examples clearly show the disadvantage that refugees have when trying to survive among the indigenous populations where they have fled. The Kakuma example is more depressing in that circumstances in camps where refugees are supposed to be safe actually expose them to malaria risk.  Overall, this is a neglected population, and unless attention is paid to conflicts and the peoples displaced by conflict, malaria cannot be eliminated.

Diagnosis &Treatment Bill Brieger | 01 Jun 2011

RDTs, unintended consequences?

Results from a recently published study on “Reduction of anti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam” are being reinterpreted.

The study found that after the introduction of malaria rapid diagnostic tests in urban Tanzania the prescription of artemisinin-based combination therapy (ACT) drugs decreased and was significantly lower in intervention health facilities than the controls, which continued existing clinical diagnostic practices. Of importance, “Adherence to test result was excellent since only 7% of negative patients received an anti-malarial.”

What has given rise to concern, is that when ACT use decreased, there was an increased use of antibiotics used to treat febrile illnesses.  By following up on the story, gathered a more detailed understanding of the implications of the finding that, “antibiotic prescription increased from 49% before to 72% after intervention.”

Valerie D’Acremont, lead author and a senior scientist at the Swiss Tropical and Public Health Institute, Switzerland, explained to that, “Clinicians were handing out antibiotics, instead of anti-malarial drugs, to all patients with fever who tested negative for malaria. ‘They do that to avoid putting patients at risk,’ she told SciDev.Net, ‘especially as there are no diagnostic tools for other diseases such as typhoid or pneumonia.'”

These concerns run counter to the enthusiasm with which RDTs have been greeted by researchers.  For example, Uzochukwu and colleagues found that RDTs are more cost effective in terms of saving lives that clinical diagnosis. Overall costs associated with RDT use was significantly lower than both clinical diagnosis and traditional microscopy.

dscn9149-sm.JPGA study in Burkina Faso showed how real life problems can interfere with research objectives when they tried to compare treatment outcomes between RDT usa and clinical diagnosis. Compliance by prescribers after getting negative RDT results was too low (i.e. they gave malaria treatment even for negative tests) to compare. Health worker acceptance of RDTs is a problem in many countries, but obviously not in the Tanzania study.

The Tanzania experience led to interview Action on Antibiotic Resistance (ReAct) that pointed out the lack of easy to use tests for other febrile conditions (pneumonia, typhoid, viral fevers) in primary care settings as a problem.  Part of the problem is lack of rigorous adherence to clinical algorithms and guidance, and possibly a desire to give anything just to make the patient happy.

Again, the lead author of the Tanzania study was quoted by as saying that, “Ideally, with training and the implementation of clinical guidelines, it’s possible to reduce antibiotic use from 80 per cent to 25 per cent of patients.” Simply put, health care providers can change their behavior.  This need for training and supervision increases as we expand treatment for febrile and other illnesses into the community.  According to MCHIP (USAID) …

Experts agree that 60% of the 9.7 million children who die annually could be spared if we just delivered the life-saving interventions that we already have to families that need them most. These interventions include: antibiotics for pneumonia, dysentery and newborn sepsis; antimalarials; and oral rehydration packets and zinc supplements for diarrhea. Unfortunately the use of these interventions is low in most developing countries because services that deliver them are not accessible, not available, not of good quality, and/or not demanded.

The call therefore is for integrated case management at all level using all the tools currently available. We certainly do not want children to survive because of better malaria case management, while at the same time spurring antibiotic resistance that will threaten those same lives.


One final note – the Tanzania study was based in an urban setting. Urban areas are generally less hospitable to malaria-carrying anopheles mosquitoes. One therefore wonders if the apparent large increase in antibiotic use was a result of fewer expected actual malaria cases in a city? Do we need different guidelines and training to orient health workers to the different ecological settings where malaria is endemic?

Advocacy Bill Brieger | 01 Jun 2011

Ghana – opportunity for advocacy at RBM impact series launch

by Emmanuel Fiagbey, Ghana Country Director, Johns Hopkins University Center for Communication Programs, Voices for a Malaria Free Future Project

Malaria advocates in Ghana celebrated worldwide successes and renewed commitments to the fight against malaria at the launch of the Roll Back Malaria (RBM) partnership’s Progress and Impact (P&I) Series reports, an event organized by Voices for a Malaria-Free Future with support from RBM and the National Malaria Control Program (NMCP) of the Ghana Health Service.

The report launch and distribution convened stakeholders including the Minister of Health and the Minister of Women and Children’s Affairs, representatives of multilateral organizations, public and private sector partners, and members of the media. More than 100 participants took part in the May 27 event themed “Achieving Progress and Impact in the Fight against Malaria.”

The six reports launched included 1) Malaria Funding and resources utilization; 2) Saving lives with malaria control; 3) Mathematical modelling to support malaria control and elimination; 4) World Malaria Day 2010 Africa updates; 5) Focus on Senegal; and 6) Business investing in malaria control. Economic returns and a healthy workforce for Africa.

moh-launches-rbm-impact-progress-reports-sm.jpgIn officially launching the reports in Ghana, Hon. Minister of Health Mr. Joseph Yieleh Chireh (MP) (see at left) noted that in the past ten years, almost three quarters of a million children in 34 African countries avoided malaria-related deaths through the use of insecticide treated nets, indoor residual spraying, effective medicines and preventive treatment during pregnancy, citing the reports.

But malaria still carries a significant burden in Ghana, he added. “The achievement of our Better Ghana Agenda, which aims at improving the lives and living conditions of our people, hinges on our total commitment and support for all efforts directed at eliminating malaria,” he said. “The recommendations made in the reports being launched today, I must emphasize, should be the gold standard for all our countries in our march towards eliminating malaria.”

In a message on behalf of the mothers and children of Ghana, the Hon. Minister of Women and Children’s Affairs Mrs. Juliana Azumah-Mensah (MP) said, “These reports will no doubt offer accurate statistics regarding malaria infections among women and children and help us know where to step up our efforts.”  She called on all who still sell or use Sulphadoxine Pyrimethamin (SP) for treating uncomplicated malaria to stop the practice, “as the loss of the efficacy of this medicine to resistance will spell doom for all pregnant women and the babies they carry,” she emphasised.

The occasion offered an opportunity to advocate in Ghana for …

  • increased resource commitments from donors and endemic country governments
  • better access to and education about cost-effective prevention interventions and rapid .diagnostic tests
  • stronger enforcement of drug policies
  • fewer taxes and tariffs on life-saving intervention tools
  • continued investments in behaviour change communication

Prof.  Fred Binka, Dean of the School of Public Health of the University of Ghana, Legon who chaired the event called on stakeholders to work together to achieve national targets, in line with these recommendations. He stressed, “With progress in individual countries, we need more sub-regional work among neighbouring countries. Mosquitoes don’t recognize political borders.”